Antimicrobial Stewardship Research Articles

The Role of Value-Based Healthcare in enhancing Antimicrobial Stewardship for End-of-Life Patients.

The Role of Value-Based Healthcare in enhancing Antimicrobial Stewardship for End-of-Life Patients.

Nephrology: What You May Have Missed in 2023.

This article highlights a selection of important nephrology studies published in 2023 that have relevance for nonnephrologist physicians. Four studies examined progression of chronic kidney disease or cardiovascular disease with respect to finerenone use, magnesium supplementation, iron markers, and COVID-19. Two studies examined treatments to improve specific aspects of chronic kidney disease management, including daprodustat to address anemia and patiromer to address hyperphosphatemia. One study showed that acetazolamide added to loop diuretics increased diuresis in acute decompensated heart failure across a wide range of renal function. Another study found that once-daily hydrochlorothiazide did not prevent kidney stone recurrence. Finally, an antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infection in frail older adults.

Antibiotics Not Associated with Shorter Duration or Reduced Severity of Acute Lower Respiratory Tract Infection.

Antibiotic use remains common for the treatment of lower respiratory tract infections. The objective of this study was to evaluate the impact of antibiotic use on the duration and severity of acute lower respiratory tract infection (LRTI). Adult patients presenting to US primary or urgent care sites with a chief complaint of cough and symptoms consistent with LRTI. Collected data included demographics, comorbidities, symptoms, and 48 viral and bacterial respiratory pathogens by PCR. Severity of signs/symptoms was reported for up to 28days using diaries and text messages. Interpolation was used where data were missing. Of 718 patients with baseline data, 29% had an antibiotic prescribed at baseline. The most common antibiotics were amoxicillin-clavulanate, azithromycin, doxycycline, and amoxicillin in 85% of patients. Provision of an antibiotic had no effect on the duration or overall severity of cough, including in patients with viral, bacterial, and mixed infections. Receipt of an antibiotic did reduce the likelihood of a follow-up visit (14.1% vs 8.2%, aOR 0.47, 95% CI 0.26-0.84), perhaps by removing the motivation of getting an antibiotic at a follow-up visit. However, they were also more likely to receive a systemic corticosteroid (31.9% vs 4.5%, p < 0.001) and were also more likely to receive an albuterol inhaler (22.7% vs 7.6%, p < 0.001). Patients believed that receiving an antibiotic would reduce the duration of their illness by nearly 4days. In this large prospective study in the US primary and urgent care setting, antibiotics had no measurable impact on the severity or duration of cough due to acute LRTI. Patients had unrealistic expectations regarding the duration of LRTI and the effect of antibiotics which should be the target of antibiotic stewardship efforts.

Identifying veterinary surgeons' barriers to, and potential solutions for, improving antimicrobial stewardship among sheep farmers in Northern Ireland.

In order to improve antimicrobial stewardship (AMS), including changes in antimicrobial prescribing and use, an enhanced understanding is needed of the barriers that veterinary surgeons (vets) encounter to institute such change. A qualitative approach, using grounded theory, was followed. Interviews and discussion groups, with vets and farm industry stakeholders in Northern Ireland (NI), were undertaken to identify and explore attitudes and behaviours surrounding AMS, with a particular emphasis on the barriers vets encountered and the context within which they were working. Seven inter-related themes associated with improving AMS among their sheep farming clients were identified. The first six addressed barriers were working under commercial and practical constraints, farmer behaviour, multiple medicine sources, poor prescribing practice, a perceived lack of incentive or facilitation to improve AMS and a perceived lack of action by regulators to challenge poor AMS. The seventh theme revealed suggestions vets considered that may improve AMS in NI, including greater state intervention in recording and regulating medicine sales. Improving AMS will require vets and their client farmers to change behaviour. This will involve concerted effort over an extended period of time to enact and embed change. Veterinary surgeons believe that further action by the industry and state to develop centralised antimicrobial sales recording and by the state to enforce prescribing regulations will aid their efforts. However, critical to achieving this is the development of a sustainable and funded mechanism to create more meaningful farmer-vet consultation around flock health prior to every prescription to improve AMS and sheep welfare.

Antimicrobial Stewardship in the Emergency Department Observation Unit: Definition of a New Indicator and Evaluation of Antimicrobial Use and Clinical Outcomes

We aimed to define a novel indicator for monitoring antimicrobial use specifically in the Emergency Department Observation Unit (EDOU) and to assess the long-term impact of an institutional education-based antimicrobial stewardship program (ASP) on the antimicrobial prescribing pattern and clinical outcomes in this setting. A quasi-experimental interrupted time-series study was performed from 2011 to 2022. An educational ASP was implemented at the EDOU in 2015. To estimate changes in antimicrobial use, we designed an indicator adjusted for patients at risk of antimicrobial prescribing: defined daily doses (DDDs) per 100 patients transferred from the Emergency Department to the Observation Unit (TOs) per quarter. The number of bloodstream infections (BSIs) and the crude all-cause 14-day mortality were assessed as clinical outcomes. Antimicrobial use showed a sustained reduction with a trend change of −1.17 DDD per 100 TO and a relative effect of −45.6% (CI95% −64.5 to −26.7), particularly relevant for meropenem and piperacillin-tazobactam, with relative effects of −80.4% (−115.0 to −45.7) and −67.9% (−93.9 to −41.9), respectively. The incidence density of all BSIs increased significantly during the ASP period, with a relative effect of 123.2% (41.3 to 284.7). The mortality rate remained low and stable throughout the study period, with an absolute effect of −0.7% (−16.0 to 14.7). The regular monitoring of antimicrobial use in the EDOU by using this new quantitative indicator was useful to demonstrate that an institutional education-based ASP successfully achieved a long-term reduction in overall antimicrobial use, with a low and steady BSI mortality rate.

Implementatie van de Infectierisicoscan in een ziekenhuisnetwerk door het Hospital Outbreak Support Team

Implementation of the Infection Risk Scan in a hospital network by the Hospital Outbreak Support Team The Infection Risk Scan (IRIS) assesses the quality of infection prevention and control (IPC) and antimicrobial stewardship (AMS) in a hospital ward by the standardized measurement of a broad range of quality indicators. IRIS was implemented in the geriatric wards of the 4 hospitals of the Plexus healthcare network ‘Oost-Vlaams-Brabant’ (Belgium). The goal was to compare the IPC and AMS policies of the hospitals in order to define common improvement strategies within the Hospital Outbreak Support Team (HOST), a federal project concerning IPC and AMS. In the first part of IRIS, the risk profile of the patient population is determined by a point prevalence measurement of 4 variables. In the second part, the improvement plot is created based on the measurement of 7 quality indicators. Improvement actions can be deduced from quality indicators with higher improvement potentials. The risk profiles of the 4 hospitals were highly comparable and the improvement plots showed an intermediate to high improvement potential for the use of AMT and hand hygiene compliance. There were important differences in the appropriate use of transurethral and intravascular catheters, with 2 hospitals having a low and 2 hospitals having a high improvement potential. IRIS was a useful tool in the early phase of the HOST project to benchmark the IPC and AMT policies between the Plexus hospitals and to decide what future projects could be collaborated on. As a result of IRIS, it was decided to define common care bundles for the prevention of catheter-associated urinary tract and blood stream infections and to determine hospital-specific actions with regard to the optimisation of AMS.

Molecular Characterization and Analysis of Risk Factors Associated with Brucellosis in Central Indian and Meghalaya Population.

Objective: In this study we evaluated the utility of Abortus Melitensis Ovis Suis Brucella PCR (AMOS PCR) for the molecular characterization of Brucella species and analyzed the associated risk factors for brucellosis in Central Indian and Meghalayan population. Methods: AMOS PCR was carried out in a total of 160 BSCP-31 PCR-positive DNA samples isolated previously from the blood of Central Indian (n = 90) and Meghalayan cohorts (n = 70). Clinical and associated risk factors recorded earlier were used to establish strain-specific disease outcomes in study cohorts. Results: Brucella melitensis was found to be the dominant strain in both Central Indian and Meghalayan cohorts (57.7% and 54.28%, respectively) followed by Brucella abortus (42.22% and 38.57%). Although rare, brucellosis cases in the Meghalayan population also showed the presence of Brucella suis (7.14%) and Brucella ovis (2.85%). Febrile illness was a major clinical risk factor in both study cohorts, while occupational risk factors like exposure to animals and raw milk consumption were major mediating factors for brucellosis in Central Indian cohorts. On the contrary, meat consumption was found to be significant predisposing factor for brucellosis in Meghalaya. Conclusion: Molecular characterization of Brucella species provides important public health data for mitigation, advocacy, and antimicrobial stewardship.

Expression of Concern: Rahman et al. An Overview of Antimicrobial Stewardship Optimization: The Use of Antibiotics in Humans and Animals to Prevent Resistance. Antibiotics 2022, 11, 667

With this notice, the Antibiotics Editorial Office states its awareness of concerns relating to the originality of the concepts and analysis published in this review [...]

The Use of Next Generation Sequencing to Detect Early Implant Infections: The Future of Microbiology and Targeted Antibiotic Treatment

Abstract Goals/Purpose The presence of fluid around foreign bodies, particularly breast implants, is a well-established phenomenon; However scant data exists regarding the composition of this fluid. The difficulty in studying this fluid arises from the lack of safe access to aspirate fluid post-breast augmentation, and by the loss of sterility once fluid exits the body via a drain bulb as traditionally placed during breast reconstruction. Our innovative breast reconstruction approach utilizes a drainless technique with a dual chamber tissue expander (TE) in the pre-pectoral plane, offering a unique avenue to sterilely aspirate peri-implant fluid through a percutaneous drainage port. In this study, we employ Next Generation Sequencing (NGS), utilizing polymerase chain reaction technology, to discern the composition of microbial DNA within peri-prosthetic breast implant fluid. NGS, known for its precision and cost-effectiveness, circumvents the biases inherent in traditional culture methods. By integrating this cutting-edge technology with our breast reconstruction methodology, we sought to study peri-prosthetic breast implant fluid to better understand when implant infections arise and if peri-prosthetic fluid could detect infections before clinical symptoms arise. Methods/Technique This is a single surgeon, prospective study of patients undergoing mastectomy, followed by pre-pectoral, drainless, TE reconstruction. Peri-prosthetic fluid was collected through the TE drainage port in the OR immediately after closure, at 1 week post op, and 3 weeks post op. This fluid was sent for traditional culture and NGS. Patients were observed for signs of infection, antibiotics, return to OR, or implant loss. Results/Complications 33 breasts from 20 patients were included. Patients had a mean age of 50 years. The average length of drainage was 21 days post-operative, with a mean of 131 cc of fluid drained per breast per week. Eight breasts had concern for skin necrosis. In 25 breasts (76%), complete sterility was achieved at the end of the case with no NGS detection of microorganisms in the initial peri-implant fluid sample. However, NGS detected microorganisms in the initial sample in 8 breasts (24%). In 5 of these 8 breasts, microorganisms were cleared by the 1-week sample and another 2 cleared by 3 weeks. The remaining 1 breast continued to have positive NGS and developed clinical signs of infections by week 2, which were not picked up by traditional culture until week 3. One breast with skin necrosis developed a positive NGS at week 3 and clinical signs of infection at week 4. No other clinical infections were seen throughout the study. Conclusion We are one of the first groups to demonstrate the ability to achieve peri-implant sterility at the time of implant insertion in the operating room. This could have significant implications for understanding the necessity of peri-operative antibiotics following breast implant placement. Our investigation into the microbial composition of ostensibly "sterile" peri-prosthetic breast implant fluid provides insight into when microorganisms arise and when they become clinical infections. These promising preliminary results suggests that peri-prosthetic fluid monitoring through Next-Generation Sequencing (NGS) holds significant potential in preemptively detecting implant infections before the onset of clinical symptoms, thereby reducing infection rates. Furthermore, our findings open avenues for targeted antibiotic therapy, contributing to the imperative goal of antibiotic stewardship. Ongoing work is beginning to explore the impact of microorganisms within the fluid on breast capsule formation, as we strive to enhance our understanding of breast implants and infections.

State of the Art Review: Evidence based management of acute appendicitis

Introduction: Even though acute appendicitis is the world’s most common emergency general surgical operation, it remains under-researcher with wide variations in care. The aim of this review was to present current evidence on the management of acute appendicitis, focusing on risk assessment, diagnostic modalities, treatment strategies, and special considerations for specific patient populations.&#x0D;  &#x0D; Methods: The writing group conducted a modified Delphi to prioritise topic areas for inclusion in this review. Consensus was achieved when each topic had &gt;70% for either important or strongly important. Scoping reviews of current and grey literature were conducted to identify relevant evidence, focussing on new publications in the last 5 years (2019-2024).&#x0D;  &#x0D; Results: Validated risk scoring systems, such as the Adult Appendicitis Score and the AIRS score, aid in identifying low-risk patients suitable for ambulatory management, while imaging modalities, including CT scans and ultrasound, play a pivotal role in confirming diagnosis and guiding treatment decisions. The review highlights the efficacy of surgical intervention versus antibiotic therapy, emphasising the importance of shared decision-making and individualised treatment plans. Tailored care strategies are needed for elderly patients, pregnant women, and those with appendiceal neoplasms whilst strategies for optimising antibiotic stewardship, minimising negative appendectomy rates, and enhancing postoperative care will provide the best evidence-based care.&#x0D;  &#x0D; Discussion: This review provides evidence-based practices can be integrated into routine clinical care and ongoing education for frontline clinicians. The practice recommendations are designed to be evidence based and can be tailored depending on local resources. These should form the basis of future educational packages and surgical training programmes.&#x0D;  

The role of community pharmacists and their perception towards antimicrobial stewardship in Baghdad, Iraq

AbstractBackgroundThis study aimed to assess the role of community pharmacists and their perception toward antimicrobial stewardship, in addition to identifying factors influencing their perception and practices in community pharmacy.MethodsA cross‐sectional study was carried out among community pharmacists regarding antimicrobial stewardship. Convenience sampling was used to obtain the required sample from a community pharmacy in Baghdad. In total, 381 participants have completed the survey.ResultsThe majority of the participants (85.6%) strongly agreed/agreed that “antimicrobial stewardship programs reduce the problems of antibiotic resistance”; and 85.5% of them strongly agreed/agreed that community pharmacists required adequate training on antibiotics use. In addition, high percent of community pharmacists (88.4%) strongly agreed/agreed that pharmacists have a responsibility to take a prominent role in antimicrobial stewardship programs and infection‐control programs in the health system. The total score of perception was significantly influenced by older age groups, postgraduate degrees, and experience of 6–10 years (p &lt; 0.001). This study also showed that 65.4% of pharmacists always/often advise patients to continue the full course of antimicrobials, and 64.9% of them reported always/often considering clinical and safety parameters before dispensing antibiotics. The role of pharmacists was significantly influenced by the younger age group, females, higher degree in pharmacy, experience of 3–5 years, and medical complex pharmacy (p &lt; 0.001).ConclusionCommunity pharmacists have a good perception toward antimicrobial stewardship programs, but their role is still limited. More efforts are needed to design better strategies for antimicrobial stewardship in community pharmacy.

Difficult-to-treat (DTR) Pseudomonas aeruginosa harboring Verona-Integron metallo-β-lactamase (blaVIM): infection management and molecular analysis.

Pseudomonas aeruginosa harboring Verona Integron-encoded metallo-β-lactamase enzymes (VIM-CRPA) have been associated with infection outbreaks in several parts of the world. In the US, however, VIM-CRPA remain rare. Starting in December 2018, we identified a cluster of cases in our institution. Herein, we present our epidemiological investigation and strategies to control/manage these challenging infections. This study was conducted in a large academic healthcare system in Miami, FL, between December 2018 and January 2022. Patients were prospectively identified via rapid molecular diagnostics when cultures revealed carbapenem-resistant P. aeruginosa. Alerts were received in real time by the antimicrobial stewardship program and infection prevention teams. Upon alert recognition, a series of interventions were performed as a coordinated effort. A retrospective chart review was conducted to collect patient demographics, antimicrobial therapy, and clinical outcomes. Thirty-nine VIM-CRPA isolates led to infection in 21 patients. The majority were male (76.2%); the median age was 52 years. The majority were mechanically ventilated (n = 15/21; 71.4%); 47.6% (n = 10/21) received renal replacement therapy at the time of index culture. Respiratory (n = 20/39; 51.3%) or bloodstream (n = 13/39; 33.3%) were the most common sources. Most infections (n = 23/37; 62.2%) were treated with an aztreonam-avibactam regimen. Six patients (28.6%) expired within 30 days of index VIM-CRPA infection. Fourteen isolates were selected for whole genome sequencing. Most of them belonged to ST111 (12/14), and they all carried blaVIM-2 chromosomally. This report describes the clinical experience treating serious VIM-CRPA infections with either aztreonam-ceftazidime/avibactam or cefiderocol in combination with other agents. The importance of implementing infection prevention strategies to curb VIM-CRPA outbreaks is also demonstrated.

A Review on Colistin Resistance: An Antibiotic of Last Resort

Antibiotic resistance has emerged as a significant global public health issue, driven by the rapid adaptation of microorganisms to commonly prescribed antibiotics. Colistin, previously regarded as a last-resort antibiotic for treating infections caused by Gram-negative bacteria, is increasingly becoming resistant due to chromosomal mutations and the acquisition of resistance genes carried by plasmids, particularly the mcr genes. The mobile colistin resistance gene (mcr-1) was first discovered in E. coli from China in 2016. Since that time, studies have reported different variants of mcr genes ranging from mcr-1 to mcr-10, mainly in Enterobacteriaceae from various parts of the world, which is a major concern for public health. The co-presence of colistin-resistant genes with other antibiotic resistance determinants further complicates treatment strategies and underscores the urgent need for enhanced surveillance and antimicrobial stewardship efforts. Therefore, understanding the mechanisms driving colistin resistance and monitoring its global prevalence are essential steps in addressing the growing threat of antimicrobial resistance and preserving the efficacy of existing antibiotics. This review underscores the critical role of colistin as a last-choice antibiotic, elucidates the mechanisms of colistin resistance and the dissemination of resistant genes, explores the global prevalence of mcr genes, and evaluates the current detection methods for colistin-resistant bacteria. The objective is to shed light on these key aspects with strategies for combating the growing threat of resistance to antibiotics.

In vitro activity of antibiotics potentially effective against difficult-to-treat strains of Gram-negative rods: retrospective study

Bacterial resistance surveillance is one of the main outputs of microbiological laboratories and its results are important part of antimicrobial stewardship (AMS). In this study, the susceptibility of specific bacteria to selected antimicrobial agents was tested. The susceptibility of 90 unique isolates of pathogens of critical priority obtained from clinically valid samples of ICU patients in 2017–2021 was tested. 50% of these fulfilled difficult-to-treat resistance (DTR) criteria and 50% were susceptible to all antibiotics included in the definition. 10 Enterobacterales strains met DTR criteria, and 2 (20%) were resistant to colistin (COL), 2 (20%) to cefiderocol (FCR), 7 (70%) to imipenem/cilastatin/relebactam (I/R), 3 (30%) to ceftazidime/avibactam (CAT) and 5 (50%) to fosfomycin (FOS). For Enterobacterales we also tested aztreonam/avibactam (AZA) for which there are no breakpoints yet. The highest MIC of AZA observed was 1 mg/l, MIC range in the susceptible cohort was 0.032–0.064 mg/l and in the DTR cohort (incl. class B beta-lactamase producers) it was 0.064–1 mg/l. Two (13.3%) isolates of Pseudomonas aeruginosa (15 DTR strains) were resistant to COL, 1 (6.7%) to FCR, 13 (86.7%) to I/R, 5 (33.3%) to CAT, and 5 (33.3%) to ceftolozane/tazobactam. All isolates of Acinetobacter baumannii with DTR were susceptible to COL and FCR, and at the same time resistant to I/R and ampicillin/sulbactam. New antimicrobial agents are not 100% effective against DTR. Therefore, it is necessary to perform susceptibility testing of these antibiotics, use the data for surveillance (including local surveillance) and conform to AMS standards.

Building the future of ID: A call to action for quality improvement research and measurement.

Quality is central to value-based care and measurement is essential for assessing performance and understanding improvement over time. Both value-based care and methods for quality measurement are evolving. Infectious Diseases has been less engaged than other specialties in quality measure development, and Infectious Diseases providers must seize the opportunity to engage with quality measure development and research. Antimicrobial stewardship programs are an ideal starting point for Infectious Diseases-related quality measure development; antimicrobial stewardship program interventions and best practices are Infectious Diseases-specific, measurable, and impactful, yet grossly undercompensated. Herein, we provide a scheme for prioritizing research focused on development of Infectious Diseases-specific quality measures. Maturation of quality measurement research in Infectious Diseases, beginning with an initial focus on stewardship-related conditions then expanding to non-stewardship topics, will allow Infectious Diseases to take control of its future in value-based care, and promote the growth of Infectious Diseases through greater recognition of its value.

Serotype diversity and antimicrobial susceptibility profiles of Actinobacillus pleuropneumoniae isolated in Italian pig farms from 2015 to 2022

Actinobacillus pleuropneumoniae (APP) is a bacterium frequently associated with porcine pleuropneumonia. The acute form of the disease is highly contagious and often fatal, resulting in significant economic losses for pig farmers. Serotype diversity and antimicrobial resistance (AMR) of APP strains circulating in north Italian farms from 2015 to 2022 were evaluated retrospectively to investigate APP epidemiology in the area. A total of 572 strains isolated from outbreaks occurring in 337 different swine farms were analysed. The majority of isolates belonged to serotypes 9/11 (39.2%) and 2 (28.1%) and serotype diversity increased during the study period, up to nine different serotypes isolated in 2022. The most common resistances were against tetracycline (53% of isolates) and ampicillin (33%), followed by enrofloxacin, florfenicol and trimethoprim/sulfamethoxazole (23% each). Multidrug resistance (MDR) was common, with a third of isolates showing resistance to more than three antimicrobial classes. Resistance to the different classes and MDR varied significantly depending on the serotype. In particular, the widespread serotype 9/11 was strongly associated with florfenicol and enrofloxacin resistance and showed the highest proportion of MDR isolates. Serotype 5, although less common, showed instead a concerning proportion of trimethoprim/sulfamethoxazole resistance. Our results highlight how the typing of circulating serotypes and the analysis of their antimicrobial susceptibility profile are crucial to effectively manage APP infection and improve antimicrobial stewardship.

Understanding antibiotic knowledge, attitudes, and practices: a cross-sectional study in physicians from a Colombian region, 2023.

Antibiotic resistance has been identified as a global health threat. Knowledge, attitudes, and inappropriate prescription practices of antibiotics by physicians play a crucial role in this problem. In Colombia, research addressing this issue is scarce. A cross-sectional study involving 258 physicians was conducted. A scale with questions on sociodemographic aspects, level of education, satisfaction with antibiotic education received, and knowledge, attitudes, and practices was administered. The scale was designed for each item to be analyzed individually or as a total score ranging from 0 to 100 (0 being the lowest and 100 the highest). 31.5% of physicians rated the education received on antibiotics as fair to poor. The knowledge score was 80.1 (IQR 70.5-87.5); however, 25.2% agreed to some extent that amoxicillin is useful in treating most respiratory infections, and 15% agreed that antibiotics are effective in treating upper respiratory infections. Attitudes scored 80.2 (IQR 75.0-86.5), with 99% stating that bacterial resistance is a public health problem in Colombia, but only 56.9% considering it a problem affecting their daily practice. Practices scored 75.5 (IQR 68.8-81.2), and 71.7% affirmed that if they refuse to prescribe antibiotics to a patient who does not need them, the patient can easily obtain them from another physician. General practitioners were found to have lower scores in all three indices evaluated. The study reveals enduring misconceptions and concerning practices in antibiotic prescription, particularly among general practitioners. Enhancing knowledge necessitates the implementation of continuous medical education programs that focus on updated antibiotic guidelines, and resistance patterns. Fostering positive attitudes requires a culture of trust and collaboration among healthcare professionals. Practical enhancements can be realized through the establishment of evidence-based prescribing guidelines and the integration of regular feedback mechanisms. Moreover, advocating for the inclusion of antimicrobial stewardship principles in medical curricula is crucial, emphasizing the significance of responsible antibiotic use early in medical education.

PREVALENCE OF FLUOROQUINOLONES RESISTANCE AMONG ESBL-PRODUCING ESCHERICHIA COLI ISOLATED FROM URINE SAMPLES

BACKGROUND&#x0D; Resistance among uropathogens has emerged as a growing concern necessitating re-evaluation of the efficacy of recommended empiric antimicrobial regimens. Misuse and overuse of various antibacterial agents in hospitals is a key cause of the emergence of anti-microbial resistance.&#x0D; Aims: To identify the prevalence of extended-spectrum beta-lactamase (ESBL) producing Escherichia coli from urine specimens and to know the prevalence of Fluoroquinolone resistance among ESBL-producing Escherichia coli (E. coli) isolates.&#x0D; Material and method: The study was conducted on 500 E. coli isolates from urine samples received in the Department of Microbiology, MMIMSR, Mullana, Ambala. The organism isolation and identification were done as per the standard procedures and antibiotic sensitivity testing was done following CLSI guidelines. All the strains were screened out for ESBL production as per CLSI guidelines. Ciprofloxacin, Norfloxacin, and Ofloxacin discs were used for the detection of fluoroquinolone resistance.&#x0D; Results: Out of the total 500 E. Coli isolates from urine samples received in our laboratory, 69% were found to be ESBL producers.&#x0D; Conclusion: We found a high level of quinolone resistance among ESBL-producing Escherichia coli strains isolated from patients with UTI. Because of the widespread use of fluoroquinolones in our country, there is a need for sensitive antibiotic stewardship.  Further research is needed to ascertain the gravity of quinolone resistance and to swiftly act against its spread among other nosocomial pathogens.&#x0D;  

A Critical Need: More Data on Antimicrobial Stewardship Programs in Critical Access Hospitals

A Critical Need: More Data on Antimicrobial Stewardship Programs in Critical Access Hospitals

Assessment of drug utilization and potentially inappropriate medications in hemodialysis patients with end-stage renal dysfunction: A study in a tertiary care hospital in Bahrain.

Patients undergoing dialysis pose therapeutic challenges in terms of polypharmacy, administration of potentially inappropriate drugs, and drugs with the potential risk of toxicity. This study evaluated the use of drugs, potentially inappropriate medicines (PIM), drugs with risk of Torsades de Pointes (TdP), and the complexity of the prescribed regimen using the medication regimen complexity index scale in patients undergoing hemodialysis. A retrospective cohort study was carried out amongst patients receiving hemodialysis. Drugs were classified into one of four classes: (i) drugs used in managing renal complications, (ii) cardiovascular drugs, (iii) anti-diabetic drugs, (iv) drugs for symptomatic management, and (v) others. Drugs were considered as PIM according to the Can-SOLVE CKD working group from a network of Canadian nephrology health professionals. The study adhered to the CredibleMeds classification of drugs with known, possible, and conditional risk of TdP and the complexity of prescribed medicines was evaluated based on the pre-validated medication regimen complexity index scale based on form/route, frequency of dosing, and requirement of special instructions. Sixty-three participants were included in the study (49 males and 14 females) with the median (range) age of 45 (21-66) years. Cardiovascular drugs followed by drugs used for managing renal complications were the most common classes administered. Notably, 12 (19.1%) patients received one of the non-steroidal anti-inflammatory drugs, 21 (33.3%) received a proton pump inhibitor, three (4.8%) received pregabalin, two (3.2%) received opioid drugs, and one (1.6%) was administered celecoxib. Atorvastatin, furosemide, omeprazole, and allopurinol were the most common PIM drugs administered to the study participants followed by others. Drugs used for symptomatic management had significantly more PIM compared to other classes (p <0.0001). Six (9.5%) patients received drugs with known TdP risk, one with possible TdP risk, and 61 with conditional risk. Median (range) medical regimen complexity index score was 26.5 (2-62.5). A huge burden of drug therapy was observed in the hemodialysis patients in terms of higher proportions of PIM, complex medical regimen, and prescription of drugs with risk of TdP. Implementation of clinical decision support tools enhancing rational prescription and identification of drugs with TdP risk, introducing antimicrobial stewardship, and stepwise deprescription of the drugs with the least benefit-risk ratio are warranted.